Taylor Burnham

Objectives: Epidural spinal cord stimulation (SCS) is an emerging therapy for motor rehabilitation following spinal cord injury (SCI) and other motor disorders. Conventionally, SCS leads are placed along the dorsal spinal cord (SCSD), where stimulation activates large diameter afferent fibers, which indirectly activate motoneurons through reflex pathways. This leads to broad activation of flexor and extensor muscles and limited fine-tuned control of motor output. Targeting the ventral spinal cord (SCSV) may enable more direct activation of motoneuron pools, potentially improving the specificity of muscle activation; however, there is currently no established method to place leads ventrally. To address this, we evaluated the feasibility of four modified percutaneous implantation techniques to target the ventrolateral thoracolumbar spinal cord. Materials and methods: Percutaneous SCSV implantation was performed in three human cadaver torso specimens under fluoroscopic guidance. The following approaches were evaluated: sacral hiatus, transforaminal, interlaminar contralateral, and interlaminar ipsilateral. The leads in the latter 3 approaches were inserted between L1 and L5. Eighteen implants were attempted, with nine leads retained for analysis. Lead and electrode position were assessed using computed tomography (CT) with three-dimensional reconstruction, along with anatomical dissection to verify lead and electrode placement within the epidural space. Results: Successful ventral epidural lead placement was achieved using all four implantation approaches. The sacral hiatus (16/16 electrodes) and transforaminal (8/8 electrodes) approaches resulted in exclusively ventrolateral placement. The interlaminar contralateral approach led to 27/32 electrodes positioned ventrolaterally and 5/32 dorsally. The interlaminar ipsilateral implantation approach led to 14/32 electrodes positioned ventrolaterally and 18/32 positioned ventromedially. Conclusions: These findings demonstrate that ventral epidural SCS lead placement can be achieved using modified percutaneous implant techniques. The four approaches outlined here provide a clinically feasible pathway to SCSV and establishes a foundation for future clinical studies investigating SCSV for motor rehabilitation following SCI.

Background: Radicular symptoms from lumbosacral spinal stenosis (LSS) are commonly managed with conservative measures, including transforaminal epidural steroid injection (TFESI). However, repeated use may cause systemic side effects in some patients. Human amniotic fluid filtrate (hAF), containing anti-inflammatory, neuroprotective, and regenerative factors, has shown therapeutic potential in pre-clinical models and other medical conditions. Objectives: Compare the safety and effectiveness of transforaminal epidural injections with hAF versus dexamethasone for treating radicular pain from LSS. Design: Double-blinded, prospective, randomized comparative trial. Methods: Fifty-eight participants were included, with outcomes assessed at 3 weeks, 6 weeks, 3 months (primary endpoint), and 6 months. Primary outcomes were adverse events (AEs) and proportions of participants reporting ≥50% numerical pain rating scale (NPRS) back and leg pain reductions at 3 months. Secondary outcomes included Oswestry Disability Index (ODI), Swiss Spinal Stenosis Questionnaire (SSSQ), and PROMIS Physical Health Summary (PHS). Linear mixed-effects models evaluated between-group differences while accounting for repeated measures. Results: At 3 months, a significantly greater proportion of participants receiving dexamethasone achieved ≥50% reductions in back pain (45.8% [95%CI = 27.9%-64.9%] vs. 15.0% [95%CI = 5.2%-36.0%]; P = .050) and leg pain (60.0% [95%CI = 40.7%-76.6%] vs. 25.0% [95%CI = 11.2%-46.9%]; P = .034) compared with hAF. Secondary outcome trends similarly favored dexamethasone at 3 months. Mixed-effects models showed greater improvements to 6-week pain and function scores with dexamethasone relative to hAF. Group AE rates were comparable, and no serious intervention-related AEs occurred. Conclusion: Dexamethasone demonstrated significantly greater short- and intermediate-term benefits over hAF across multiple clinical outcome domains for radicular pain due to LSS, prompting early trial discontinuation. Trial Registration: ClinicalTrials.gov (NCT04537026); September 3, 2020.

Objective: To describe long-term treatment outcomes of nervus femoralis radiofrequency ablation (NF-RFA) for recalcitrant greater trochanteric pain syndrome (GTPS). Design: A cross-sectional study. Methods: Chart review of consecutive patients who underwent NF-RFA from 2022 to 2023 was performed. A standardized telephone survey was utilized to capture current Numeric Pain Rating Scale (NPRS) and Patient Global Impression of Change (PGIC) scores. The primary outcome was ≥50% NPRS score reduction at follow-up. A secondary analysis was completed on free text responses asking patients to describe post-procedural changes in pain and function in their own words. Results: Outcomes were collected from 25 patients (aged 71.7 ± 9.3 years; 80.0% female; body mass index 29.3 ± 6.8 kg/m2) for 27 NF-RFA procedures at a minimum follow-up time of 6 months post-procedure. Average follow-up time was 13.1 ± 4.9 months; ≥50% NPRS reduction from baseline was reported by 55.6% (n = 15/27; 95% CI, 37.3-72.4) of patients. In addition, ≥ 2-point NPRS score reduction from baseline was reported by 70.4% (n = 19/27; 95% CI, 51.5-84.2) of patients, and 51.9% (n = 14/27; 95% CI, 34.0-69.3) reported a PGIC score consistent with “much improved” or “very much improved.” Conclusion: In this cohort, over 55% of patients who received NF-RFA as treatment for refractory GTPS reported at least 50% improvement in hip pain at an average follow-up of approximately 13 months. The majority of free text responses from patients indicated that they would recommend NF-RFA, while approximately 25% reported ongoing pain and disability from low back pain or a return of index hip pain symptoms post-procedure.

Summary of Background Data: Multiple clinical trials have demonstrated the effectiveness of intraosseous basivertebral nerve radiofrequency ablation (BVNA) for treating chronic vertebrogenic low back pain (vLBP). Few studies have evaluated the effectiveness in a real-world population. Objectives: To evaluate the effectiveness of BVNA for vLBP in a real-world population. Methods: A single-arm prospective cohort study of patients with LBP ≥ 6 months and Type 1 or Type 2 Modic changes on MRI. The primary outcome was mean improvement in Oswestry Disability Index (ODI) post-BVNA. Secondary outcomes included the proportion of participants with (1) ≥30% and ≥15-point ODI improvements, (2) ≥2-point and ≥50% reductions in pain on Numerical Rating Scale (NRS), and (3) ≥ “much improved” on Patient Global Impression of Change (PGIC) at 3- and 12-month follow-up. Results: In total, 60 participants were included (mean age 57.0 ± 13.4 years; 45.0% female). Mean ODI score improvement was 13.9 ± 18.7 and 14.0 ± 15.7 points at 3- and 12-month follow-up, respectively. At 12 months, 52.8% (95% CI, 39.7-65.6) of participants reported ≥30% ODI improvement and 39.6% (95% CI, 27.6-53.1) of participants reported ≥15-point improvement in ODI. Twelve-month responder rates for ≥2-point and ≥50% NRS improvement were 67.9% (95% CI, 54.5-78.9) and 49.1% (95% CI, 36.1-62.1). Moreover, 54.7% (95% CI, 41.5-67.3) of participants reported being “much or very much improved” on the PGIC at 12 months. Discussion/Conclusion: In this real-world cohort, over half of participants with vLBP experienced clinically meaningful improvements in pain and function at 12-month post-BVNA. Trial Registration Details: ClinicalTrials.gov (original study: NCT04449835; continuation study: NCT05660512); [original study: June 25, 2020; continuation study: December 13, 2022].

Purpose: To assess the characteristics and effectiveness of low‐cost platelet‐rich plasma (LC‐PRP) for knee osteoarthritis (OA) by evaluating its composition and effect on pain, function, satisfaction, safety and cost‐effectiveness. Methods: Level IV evidence single‐arm prospective cohort pilot study of 20 subjects (30 knees total) with mild‐to‐moderate knee OA. Two LC‐PRP injections were performed, 3 weeks apart. Platelet extraction/yield, patient‐reported outcomes and incidence of adverse events were assessed with a primary endpoint of 6 months. A cost‐effectiveness analysis of LC‐PRP compared to corticosteroid injection was conducted. Results: On average, this LC‐PRP preparation method allowed for recovery of 85% of platelets. Significant mean differences in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores (total, pain and function) and global assessment score were observed at all follow‐up points compared to baseline ( p < 0.05 for 1, 3, 6 and 12 months). Satisfaction was noted in 90% of patients at 6 months and 75% of patients at 12 months. No significant adverse events were reported. LC‐PRP was less costly ($654 vs. $1308) and yielded more QALYs (0.846 vs. 0.708) than corticosteroid injections. Per injection costs were estimated to be $10 for corticosteroid and $11 for LC‐PRP. Conclusions: This pilot study demonstrates that LC‐PRP ($11) may significantly benefit patients with knee OA. LC‐PRP appears to be a safe, cost‐effective means for improving pain and function in knee OA. Level of Evidence: Level IV.